PROJECT SUMMARY COVID-19 has been devastating in many areas of the United States. Both the disease itself and the necessary mitigation measures have affected local communities. Local health departments have struggled to identify ways to continue to serve their communities. One population that has been affected in multiple ways is people who inject drugs (PWID). In many rural areas, harm reduction services have been closed because of the response to COVID-19, isolating many PWID. Some health departments have noted the absence of a clear emergency response plan to continue serving the vulnerable PWID population. Building on our relationships that we have established in our UG3/UH3 Rural Opioid Initiative project, referred to as the Ohio Opioid Project (OHOP), we will assess the impact of the COVID-19 pandemic on local stakeholders and PWID in southern Ohio. We will then use this information to develop an emergency management plan for two local health departments that provide the only syringe service programs in the area. This plan will form the basis of a generalizable approach that can be used elsewhere in rural areas of the U.S. The aims for this supplement are to: Aim 1) Explore the impact of COVID-19 on PWID and harm reduction services to identify strengths and gaps in emergency preparedness in Scioto and Gallia Counties (Step 1, PHEPARC). Aim 2) Assess the impact of COVID-19 on overdose and infectious diseases among PWID (Step 1, PHEPARC) Aim 3) Develop an emergency management plan for harm reduction and treatment services for use in Ohio and other states. In Aim 1, we will assess provider preparation, unanticipated and anticipated challenges, and the impact on services in the immediate aftermath of the pandemic. We will conduct 30 in-depth interviews with PWID and 30 in-depth interviews with substance use providers, first responders, and state and local emergency response officials. In Aim 2, we will explore PWID?s experiences with stigma, injection networks, overdose, syringe access, and access to care for MOUD and other health care through our respondent-driven sampling (RDS) survey. In Aim 3, we will draw from Aim 1 and 2 findings and work closely with the Ohio governmental agencies, local health departments, and our community advisory board to develop a flexible emergency response plan that can address the unique needs of rural counties. The plan will include a decision structure, communication plan, and detailed guidelines for substance use providers to mitigate the impact of future crises. Upon completion of this supplement, we will have a clear understanding of the impact of the COVID-19 pandemic on PWID and harm reduction support in rural Ohio. And we will provide a strategy to mitigate the impact of future crises on the rural PWID population in the future.